LHC versus Coronary Angiography: Take Heart When Coding

Is your provider performing a left heart catheterization every time a coronary angiography is performed? Are you coding a left heart catheterization procedure code every time you code coronary angiography procedures? Can coronary angiography be performed without a left heart catheterization? If you are unable to answer these questions with confidence, you may need to carefully re-review your procedure documentation and the ICD-10-PCS tables for these procedures. 

Many cardiovascular providers are not aware that ICD-10-PCS separates the coding of heart catheterization from coronary artery angiography procedures. A few years ago, I was fortunate to be a member of a special committee within my organization comprised of physicians, nurses, quality staff, and coding representatives. The associate professor of cardiology was also a member of this committee.

I had the opportunity to have a conversation with this physician about some confusing left heart catheterization/coronary artery angiography documentation we were seeing from the coding department. When I explained that the code set separated left heart catheterization, right heart catheterization, and coronary artery angiography with different procedure codes, the situation became clear. 

This physician explained that when he and others originally were taught to perform the left heart catheterization and coronary artery angiography procedures, it was presented that coronary angiography is a part of or included in left heart catheterization, even if only coronary artery angiography is performed. It was further explained to me that often there was no left heart catheterization being performed, but only coronary angiography, and that the trend was to perform an echocardiogram on many patients in lieu of cardiac catheterization, as it is less risky for the patient.

Many vascular surgeons may document more often than not that they are performing a left heart catheterization with a coronary angiography, even when only coronary angiography is performed. 

In ICD-10-PCS, a left heart catheterization procedure is classified to the Measurement and Monitoring Section, to the root operation of Measurement. The definition of Measurement is “determining the level of a physiological or physical function at a point in time.” Coronary angiography procedures, however, are classified to the Imaging Section, to procedure type of Fluoroscopy. Typically, a heart catheterization, whether left or right or bilateral, is performed to assess and measure the function of either side of the heart, diagnose cardiac anomalies or birth defects of the heart, and/or to perform a biopsy of the heart.

Heart catheterization is really the only way to directly measure the pressure of blood in each chamber of the heart and in the major blood vessels going from the heart to the lungs. Coronary angiography procedures are typically performed to visualize one or more of the coronary arteries, looking for stenosis and/or atherosclerosis or other abnormalities of the arteries. Coronary angiography is similar to catheterization of the left side of the heart because the coronary arteries branch off of the aorta just after it leaves the left side of the heart. 

Left heart catheterization can be performed alone or in conjunction with coronary angiography, and vice versa. Coronary angiography can be performed alone or in conjunction with left heart catheterization. Right heart catheterization can be performed alone or in conjunction with left heart catheterization and/or coronary angiography.

Often, when a left heart catheterization procedure is performed, documentation may include the visualization and/or measurement of function of the left atrium and ventricle, the mitral and aortic valves, the ascending left aorta, and possibly the pulmonary veins. Pressure measurements may be taken and recorded in the documentation. When coronary angiography is performed, documentation will include catheter insertion into one or more of the four main coronary arteries, and possibly their corresponding branches:  the left main coronary artery, left anterior descending, left circumflex, and/or right main coronary artery.

Sometimes, during the coronary angiography procedure, angioplasty (dilation) and/or stent placement in one of these arteries may be performed when deemed necessary by the performing provider.

Clues that a left heart catheterization was not performed would be the absence of catheter insertion into one or more of the left atrium and ventricle, mitral and aortic valves, ascending left aorta, and/or pulmonary veins. Quite often the patient will have an echocardiogram performed to evaluate heart function and pressures in lieu of heart catheterization, and then undergo only coronary angiography, with or without angioplasty and/or stent placement, which is much less risky for the patient than catheterizing the left and/or right heart, then moving on to catheterize the coronary arteries. 

When coding cardiovascular catheterization procedures, it is important to read the procedure documentation carefully, being mindful to code from the procedure documentation rather than the procedure titles listed at the beginning of the procedure report. It can also be very beneficial to review and clarify cardiovascular catheterization procedure documentation with your providers and open dialogue about the different coding classifications of the heart catheterization and the coronary angiography procedures. Your providers can help clarify their documentation and the procedures that are actually being performed. 

In turn, providers can understand the importance of clear procedure documentation and procedure code classification differences, aiding in appropriate procedure coding.